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SENDAGAYA INTERNATIONAL CLINIC

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Appointment Form

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When do you want to
see the doctor?  ※
  (dd/mm/yyyy) 
At what time do you
want an appointment?  ※
Name ※ Family name       Given name   
Date of birth ※   (dd/mm/yyyy)
Sex ※   Male      Female
Address ※ 〒 Postal code :
E-mail address ※
Cellular phone number  ※
  (Telephone number)
Insurance-covered treatment
For patients visiting our clinic for the first time, please fill out the details of your health insurance/insurance card below. (Information about your health insurance will be handled properly complying to the regulations on the protection of personal information. If you do not give us the details of your health insurance, we will not be able to input your data into our electronic chart, and therefore you may have to wait longer when you visit our clinic.) Insurer Number  (保険者番号)   Code  (記号)                                Number  (番号)                           Expiration date   (有効期限)
(Only national health insurance)        (yy/mm/dd) Name of householder   (世帯主氏名)  
cellular phone or to your e-mail ※ If we need to ask you something, would you like to be contacted to your cellular phone or to your e-mail address   cellular phone      e-mail       either one is OK
Only for Non-Japanese Health Insurance Holders. Do you need the documents for insurance claim?   No        Yes
question.1 Are you allergic to any drug or injection?   No.   Yes     ※ If yes, please write about it in detail.
question.2 What is your problem today?
Please give us your main symptoms (1 to 3 symptoms) or your reason for coming. eg. 1 ) I would like to have medication for high blood pressure.
eg. 2 ) I have rashes on my body and have a fever of 38℃
eg. 3 ) I have stomachache, diarrhea and vomiting
 * If you come for a different reason than feeling sick, please jump to question 7.
question.3 Do you have fever?   No   Yes      degrees  
question.4 Do you have a cough?   No, I don't.   I have a mild cough.   I have a rather bad cough.   I have a bad cough.
question.5 Do you have stomachache?   No, I don't.   Yes, slightly.    I have a bad stomachache.
question.6 Do you have diarrhea?   No, I don't.   I have slightly loose stool.    I have watery stool.
question.7 Please write your symptoms in detail, such as; ‘which part of your body’ do you have problem with, ‘since when,’ ‘what happened’ and ‘what you are worried about,’ so that you can explain it when the doctor examines you. If you write them in detail, it will save a lot of your time at the clinic. Symptoms (‘What happened,’ ‘to which part of your body,’ ‘since when’ are essential.)
question.8 Do you have any requests when you see the doctor? (Mark all that apply)   I want to have medication.   I want to have a test.  I want to have injection/intravenous drip.    I want to consult about my Other
question.9 If you need a prescription for medication, for how many days?
a) In case of medication for the flu, headache, stomachache, etc.   3 days   5 days    1 week    over a week b) In case of medication for asthma, high blood pressure, etc.   30 days   60 days       Days
question.10 Please tell us about any disease or injury that you have had until now.(e.g. I underwent operation for appendicitis at XX Hospital; I have been taking psychotropic drugs for 3 years, etc.)
question.11 Would you rather be prescribed generic drugs?   Yes   No  
The next two questions are for female patients only
question.12 Are you pregnant or is there a possibility that you might be pregnant?   Yes   No  
question.13 Are you currently breastfeeding?   Yes   No  
Others If there is anything you are concerned with or if you have any requests, please write them below.
【 Reservation Fee for CT scan, MRI, Endoscopy Examination 】 Emergency reservation for CT scan, MRI, and Endoscopy at affiliated
facilities may require a reservation fee. No fee for regular reservation. 【 Cancellation Fee of CT scan, MRI, Endoscopy Examination 】 Sudden Cancellation of CT scan, MRI, and Endoscopy might be required for
cancellation fee. No fee for advanced (at least 24 hours) cancellation.